Chat with us, powered by LiveChat This is a lab assignment on making a SOAP note of an acute or chronic illness. Use APA format and must include a minimum of two Scholarly Citations. Here I attach the instructio - Writingforyou

This is a lab assignment on making a SOAP note of an acute or chronic illness. Use APA format and must include a minimum of two Scholarly Citations. Here I attach the instructio

This is a lab assignment on making a SOAP note of an acute or chronic illness. Use APA format and must include a minimum of two Scholarly Citations. Here I attach the instructions and you must fill out the attached model. Please follow the Soap Notes Rubric.

Soap Note #1 Acute or Chronic Conditions

Soap Note 1 Acute or Chronic Conditions (10 Points)

Pick any "ADULT" Acute or Chronic Disease from Weeks 1-10

Must use the sample template for your soap note, keep this template for when you start clinicals. Follow the MRU Soap Note Rubric as a guide.

Use APA format and must include a minimum of two Scholarly Citations.

Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)

Turn it in Score must be less than 20% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 20%. Copy-paste from websites or textbooks will not be accepted or tolerated.

Please see the College Handbook with reference to Academic Misconduct Statement.

The use of templates is ok with regards to Turn it in, but the Patient History, CC, HPI, The Assessment and Plan should be of your own work and individualized to your made-up patient. 

This Week's Topics

· SOAP note: Adult (Any Adult or Chronic) Condition

Suggested Reading Material 

· Sample SOAP Note

· Mosby's manual of diagnostic and laboratory test (6th ed)

· Jarvis, C. (2016).  Physical examination & health assessment. Seventh edition. St. Louis, Mo.: Elsevier


· Formulate accurate differential diagnoses to promote health, prevent disease, and manage acute and chronic illness in adult and geriatric population.

· Employs screening and diagnostic strategies in the development of diagnosis.

· Demonstrate effective communication skills by performing culturally sensitive health assessment interviews. 

· Critically analyze data and evidence for improving health outcomes.


· Integrate nursing and related sciences into the delivery of care to clients in diverse healthcare settings.

· Create effective interdisciplinary organizational and systems leadership in the care of clients in diverse care settings.

· Apply practice guidelines to improve practice and health outcomes. 

· Relate information and communication technologies to document and improve practice health outcomes. 

· Employ collaborative interprofessional strategies for improving client and population health outcomes.  

· Evaluate the effectiveness of clinical prevention interventions that affect individual and population based-health outcomes, perform risk assessments, add design plans or programs of care.  

· Relate knowledge of illness and disease management to providing evidence-based care to clients, communities, and vulnerable populations in an evolving healthcare delivery system. 

This is a quick review of how to create a SOAP note.


(Student Name)

Miami Regional University

Date of Encounter:

Preceptor/Clinical Site:

Clinical Instructor:

Soap Note # ____ Main Diagnosis ______________




Gender at Birth:

Gender Identity:



Current Medications:




Preventive Care:

Surgical History:

Family History:

Social History:

Sexual Orientation:

Nutrition History:

Subjective Data:

Chief Complaint:

Symptom analysis/HPI:

The patient is …

Review of Systems (ROS) (This section is what the patient says, therefore should state Pt denies, or Pt states….. )










Objective Data:











(In a paragraph please state “your encounter with your patient and your findings ( including subjective and objective data)

Example : “Pt came in to our clinic c/o of ear pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc… on examination I noted this and that etc.)

Main Diagnosis

(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference/s as per APA style 6th or 7th Edition.

Differential diagnosis (minimum 3)


Labs and Diagnostic Test to be ordered (if applicable)

· –

· –

Pharmacological treatment:

Non-Pharmacologic treatment:

Education (provide the most relevant ones tailored to your patient)


References (in APA Style)


Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).

ISBN 978-0-8261-3424-0

Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Consult 2010

(25th ed.). Print (The 5-Minute Consult Series).



Soap Note Acute


Name: Mr. JL

Age: 49-year-old

Gender at Birth: Male

Gender Identity: Male

Source: Patient

Allergies: PCN

Current Medications:

● Hydrochlorothiazide 25 mg BID, Rosuvastatin 5 mg PO daily

PMH: Hypertension, gastritis; hypercholesterolemia

Immunizations: Influenza vaccine 2022, COVID-19 X2, tetanus, and hepatitis A and B 2 years


Preventive Care: Colonoscopy negative in 2020

Surgical History: None

Family History: Both parents alive, non-contributory

Social History: Patient lives by himself. The patient does not drink alcohol, does smoke half a

pack of cigarettes daily. The patient does drink 2 cups of coffee daily.

Sexual Orientation: Straight

Nutrition History: Diets off and on, mostly frozen foods

Subjective Data:

Chief Complaint: “headaches and muscles sore” that started one week ago

Symptom analysis/HPI:

The patient is a 49 years old male who presents to the ED with headache and muscle sore with

onset one week ago after prolonged indoor bicycling. The patient also complains of

lightheadedness, dizziness, drowsiness, lower extremities excruciating pain, nausea, and

vomiting. He describes the pain as sharp, moderate to excruciating, burning sensation, and 9/10

in intensity on both legs. Mr. Jones says activities such as standing too long exacerbate the pain

and Tylenol alleviates the pain mildly.

Review of Systems (ROS)

CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss.

NEUROLOGIC: Headache and dizziness as described above. Denies changes in LOC. Denies a

history of tremors or seizures.

HEENT: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in

vision, diplopia, or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or

drainage. Nose: Denies nasal drainage, and congestion. THROAT: Denies throat or neck pain,

hoarseness, and difficulty swallowing.

RESPIRATORY: Patient denies shortness of breath, cough or hemoptysis.

CARDIOVASCULAR: No chest pain, or tachycardia. No orthopnea or dyspnea.

GASTROINTESTINAL: Denies abdominal pain or discomfort. Denies flatulence, nausea,

vomiting, or diarrhea.

GENITOURINARY: Denies hematuria, dysuria, or change in urinary frequency. Denies

difficulty starting/stopping streams of urine or incontinence.

MUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or snapping sound.

SKIN: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.

Objective Data:

VITAL SIGNS: Blood pressure 151/75 mmHg, Pulse 75 bpm, Respiratory rate 18 rpm, Temp

99.2 ℉. Height: 5’8 in. Weight 172 lb, BMI 26.1. Report pain 9/10.

GENERAL APPEARANCE: The patient is alert and oriented x 3. No acute distress was noted.

NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, place, and time. Sensation

intact to bilateral upper and lower extremities. Bilateral UE/LE strength 5/5.

HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses have no

tenderness. Eyes: No conjunctival injection, no icterus, visual acuity, and extraocular eye

movements intact. No nystagmus was noted. Ears: Bilateral canals patent without erythema,

edema, or exudate. Bilateral tympanic membranes intact, pearly gray with a sharp cone of light.

Maxillary sinuses have no tenderness. Nasal mucosa is moist without bleeding. The oral mucosa

is moist without lesions. Lids are non-remarkable and appropriate for race.

Neck: supple without cervical lymphadenopathy, no jugular vein distention, and no thyroid

swelling or masses.

CARDIOVASCULAR: S1S2, regular rate and rhythm, no murmur or gallop noted. Capillary

refill < 3 sec.

RESPIRATORY: No dyspnea or use of accessory muscles observed. No egophony whispered

pectoriloquy or tactile fremitus on palpation. Breath sounds are present and clear bilaterally on


GASTROINTESTINAL: No mass or hernia observed. Upon auscultation, bowel sounds are

present in all four quadrants, no bruits over renal and aorta arteries. Abdomen soft non-tender, no

guarding, no rebound no distention or organomegaly noted on palpation

MUSKULOSKELETAL: Tenderness noted to palpation on lower extremities. ROM within

normal limits, no stiffness.

INTEGUMENTARY: skin intact, no lesions or rashes, no cyanosis mild jaundice noted in oral

mucosa and sclerae

Laboratory Test:

WBC 13.6

CPK 5,840

BUN 24

Sodium 134

Anion gap 2

Creatinine 1.30

Calcium 10.6

Alkaline phosphatase 31

Albumin 3.0



Total Bilirrunin




Differential diagnosis:


Complementary studies:

Pharmacological treatment:

Non-Pharmacologic treatment:





Grading Rubric


This sheet is to help you understand what we are looking for, and what our margin remarks might be about on your write ups of patients. Since at all of the white-ups that you hand in are uniform, this represents what MUST be included in every write-up.

1) Identifying Data (___5pts): The opening list of the note. It contains age, sex, race, marital status, etc. The patient complaint should be given in quotes. If the patient has more than one complaint, each complaint should be listed separately (1, 2, etc.) and each addressed in the subjective and under the appropriate number.

2) Subjective Data (___30pts.): This is the historical part of the note. It contains the following:

a) Symptom analysis/HPI(Location, quality , quantity or severity, timing, setting, factors that make it better or worse, and associate manifestations.(10pts).

b) Review of systems of associated systems, reporting all pertinent positives and negatives (10pts).

c) Any PMH, family hx, social hx, allergies, medications related to the complaint/problem (10pts). If more than one chief complaint, each should be written u in this manner.

3) Objective Data(__25pt.): Vital signs need to be present. Height and Weight should be included where appropriate.

a) Appropriate systems are examined, listed in the note and consistent with those identified in 2b.(10pts).

b) Pertinent positives and negatives must be documented for each relevant system.

c) Any abnormalities must be fully described. Measure and record sizes of things (likes moles, scars). Avoid using “ok”, “clear”, “within normal limits”, positive/ negative, and normal/abnormal to describe things. (5pts).

4) Assessment (___10pts.): Encounter paragraph and diagnoses should be clearly listed and worded appropriately including ICD10 codes.

5) Plan (___15pts.): Be sure to include any teaching, health maintenance and counseling along with the pharmacological and non-pharmacological measures. If you have more than one diagnosis, it is helpful to have this section divided into separate numbered sections.

6) Subjective/ Objective, Assessment and Management and Consistent (___10pts.): Does the note support the appropriate differential diagnosis process? Is there evidence that you know what systems and what symptoms go with which complaints? The assessment/diagnoses should be consistent with the subjective section and then the assessment and plan. The management should be consistent with the assessment/ diagnoses identified.

7) Clarity of the Write-up(___5pts.): Is it literate, organized and complete?


Total Score: ____________ Instructor: __________________________________

Guidelines for Focused SOAP Notes

· Label each section of the SOAP note (each body part and system).

· Do not use unnecessary words or complete sentences.

· Use Standard Abbreviations

S: SUBJECTIVE DATA (information the patient/caregiver tells you).

Chief Complaint (CC): a statement describing the patient’s symptoms, problems, condition, diagnosis, physician-recommended return(s) for this patient visit. The patient’s own words should be in quotes.

History of present illness (HPI): a chronological description of the development of the patient's chief complaint from the first symptom or from the previous encounter to the present. Include the eight variables (Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors, Treatment, Severity-OLDCARTS), or an update on health status since the last patient encounter.

Past Medical History (PMH): Update current medications, allergies, prior illnesses and injuries, operations and hospitalizations allergies, age-appropriate immunization status.

Family History (FH): Update significant medical information about the patient's family (parents, siblings, and children). Include specific diseases related to problems identified in CC, HPI or ROS.

Social History(SH): An age-appropriate review of significant activities that may include information such as marital status, living arrangements, occupation, history of use of drugs, alcohol or tobacco, extent of education and sexual history.

Review of Systems (ROS). There are 14 systems for review. List positive findings and pertinent negatives in systems directly related to the systems identified in the CC and symptoms which have occurred since last visit; (1) constitutional symptoms (e.g., fever, weight loss), (2) eyes, (3) ears, nose, mouth and throat, (4) cardiovascular, (5) respiratory, (6) gastrointestinal, (7) genitourinary, (8) musculoskeletal, (9-}.integument (skin and/or breast), (10) neurological, (11) psychiatric, (12) endocrine, (13) hematological/lymphatic, {14) allergic/immunologic. The ROS should mirror the PE findings section.

0: OBJECTIVE DATA (information you observe, assessment findings, lab results).

Sufficient physical exam should be performed to evaluate areas suggested by the history and patient's progress since last visit. Document specific abnormal and relevant negative findings. Abnormal or unexpected findings should be described. You should include only the information which was provided in the case study, do not include additional data.

Record observations for the following systems if applicable to this patient encounter (there are 12 possible systems for examination): Constitutional (e.g. vita! signs, general appearance), Eyes, ENT/mouth, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Skin, Neurological, Psychiatric, Hematological/lymphatic/immunologic/lab testing. The focused PE should only include systems for which you have been given data.

NOTE: Cardiovascular and Respiratory systems should be assessed on every patient regardless of the chief complaint.

Testing Results: Results of any diagnostic or lab testing ordered during that patient visit.

A: ASSESSMENT: (this is your diagnosis (es) with the appropriate ICD 10 code)

List and number the possible diagnoses (problems) you have identified. These diagnoses are the conclusions you have drawn from the subjective and objective data.

Remember: Your subjective and objective data should support your diagnoses and your therapeutic plan.

Do not write that a diagnosis is to be "ruled out" rather state the working definitions of each differential or primary diagnosis (es).

For each diagnoses provide a cited rationale for choosing this diagnosis. This rationale includes a one sentence cited definition of the diagnosis (es) the pathophysiology, the common signs and symptoms, the patients presenting signs and symptoms and the focused PE findings and tests results that support the dx. Include the interpretation of all lab data given in the case study and explain how those results support your chosen diagnosis.

P: PLAN (this is your treatment plan specific to this patient). Each step of your plan must include an EBP citation.

1. Medications write out the prescription including dispensing information and provide EBP to support ordering each medication. Be sure to include both prescription and OTC medications.

2. Additional diagnostic tests include EBP citations to support ordering additional tests

3. Education this is part of the chart and should be brief, this is not a patient education sheet and needs to have a reference.

4. Referrals include citations to support a referral

5. Follow up. Patient follow-up should be specified with time or circumstances of return. You must provide a reference for your decision on when to follow up.